1874, Vanves, outside Paris, a forty-three-year-old woman turns back into the room away from the view of the lovely purpose-built gardens that surround the private mental institution in which she lives. These are the green spaces in which melancholy patients are invited to lose themselves. She informs her physician that she has just had a strange and revelatory physical experience. Her physician is the neurologist and psychiatrist Jules Cotard. He is ten years her junior, and he listens intently as she describes an extraordinary feeling, something electrical, like lightning, which ran all the way up her back to her head, accompanied by a noise which she thought would split her in two along the spine. The event has set off a chain of thoughts and revelations about herself, her body and spirit, which has led inexorably to the conviction that she is dead.
Six years later, in 1880, Cotard presents a new illness to the medical community. He believes it to be a type of melancholia. His lecture draws upon numerous audiences with ‘Madame X’. It is delivered before the Société Médico-Psychologique in Paris on 28 June of that year, to be published in the Annales Médico-Psychologiques in September. His patient has expanded on her extraordinary experience and the sensations which came with it and he is now in a position to describe a new subcategory of the delusion type that alters a person’s view of their own body:1
Dr Jules Falret and I have had the opportunity to observe a patient suffering from a specific form of hypochondriacal delusion. Madame X complained that ‘she did not have a brain, nerves, chest, stomach or guts; all she had left was the skin and bones of her disorganised body’ (her own words).
Cotard continues, briefing the room on the key aspects to her delusion. The belief ‘seemed to have developed as an extension of earlier metaphysical ideas that her own soul, God and the devil did not exist either. She believed that, because of the state of her body, she did not need to eat, could no longer die a natural death and the only means to put an end to her life was to burn her alive. Consequently, Madame X constantly asked to be burnt alive and indeed attempted on various occasions to set fire to herself.’ This horrifying image calls to mind Simon Morin, burned alive for calling himself the Messiah, or indeed countless ‘heretics’ from previous centuries. In this case, it’s not a fate ordered by the authorities; it’s one requested by the person who would go on the fire.
Cotard then asks his audience to go back with him over the evolution of this nihilistic attitude: ‘In 1874, at the time of her admission, the patient was 43 years old and had been ill for 2½ years. Her condition had started one day when she heard that “crackling of her back extending up to her head”. After this macabre experience she became prey to constant weariness and anxiety, she felt “like a lost soul” and repeatedly sought the help of priests and doctors. She tried to kill herself on a number of occasions and she was admitted to Vanves.’ Vanves is one of many independently run asylums that have sprung up in recent years. It’s overseen by Pierre and Jules Falret. Jules has also observed ‘Madame X’.
Cotard’s observations point to a psychological crisis. The patient expressed profound guilt and shame at her own past behaviour. But it’s also a spiritual one. ‘Believing she was damned, her religious beliefs encouraged her to blame herself for all kinds of sins, particularly for having done wrong during her first communion.’ Cotard shows us a woman organising all the scattered pieces of her past into a strict religious framework. She brings to mind Francis Spira and his eternal punishment. ‘Because her life was but a string of lies and crimes, she fully deserved having been punished by God to suffer forever.’ Then came the realisation that she was dead. In her account, with its lightning bolt, this has the transcendent quality of a religious epiphany.
Shortly after her admission, she had the sudden experience that she could ‘understand the truth’. In other words, says the doctor, the ‘delusions of negation’ were now firmly fixed in place. She is unbalanced, violent (she calls acts of violence ‘acts of truth’).
We want to know what has led ‘Madame X’ to this point. But ‘Madame X’ is a person hidden behind a pseudonym, like Capgras’s ‘Madame M’, and Burton behind ‘Democritus Junior’. She’s a headline for Cotard’s new psychological phenomenon and he has to protect her anonymity. The only thing we know for sure about ‘Madame X’ is that her belief she’s already dead is unshakable.
Cotard continues with his lecture: ‘After a few months, she started to improve from her anxious melancholia. She was calmer, but in her daily interactions she became malicious and sardonic. Her delusions, however, did not change, and she continued to complain that she did not have a brain, nerves or guts, that eating was a useless torture, and that death by fire was the only solution to her woes. On examination, she showed bilateral reduced sensitivity to pain in most areas of her body: for example, she would not show any reaction when pricked by a pin. At the same time, touch, and the special sense modalities seemed all within normal range.’
Like Joseph Capgras testing ‘Madame M’s knee reflexes, Cotard is open to the possibility of biological reasons behind ‘Madame X’s delusion. She is apparently numb to pain when jabbed with a pin. Is this brain injury or neurological disease? Is it related to the tingling up her back? We can’t know that part of the story. Cotard leaves the physical examinations there. His hunch is that this is really a psychological story.
His patient has annihilated herself. She is absent. A blank. Her denial of the physical world reminds us again of Francis Spira and his delusion of despair three hundred years earlier. Cotard will write about it as a sort of reverse grandiosity. There is a profound sense of alienation in her delusion, but although it’s passive in nature it demands the same level of attention. Both individuals experience a revelation, both refuse food. Spira is plagued by guilt about his legal double dealing in pursuit of riches. ‘Madame X’ apparently believes that she has not led a good and honest life. She is tortured by this certain knowledge. As with Spira, there’s the suggestion of secrets. If people knew what she had done, they would judge her and condemn her.
It’s a puzzle. Cotard doesn’t say whether she ever divulged what she had done that was so wrong, or who she had lied to. Perhaps this was paranoia and she hadn’t done anything worthy of blame at all. Where did the delusion come from? Is there any logic to it? ‘Madame X’ is a negative impression of a woman. She’s retreated into the dark spaces. Cotard followed her there, over the course of his conversations with her, trying to shed some light and expose her, give her some definition.
The principal types of delusion have remained consistent over the centuries and the recurring themes predate the psychiatric textbooks. There is a recorded case of a living death, a total self-annihilation, many years before Cotard brought ‘Madame X’ to the world and formally described a ‘délire de négation’. This example comes to us via The Anatomy of Melancholy of 1621 by courtesy of Robert Burton’s raid on the notes of a sixteenth-century physician in the Dutch Republic, Petrus Forestus, known as the ‘Dutch Hippocrates’. Forestus tells the story of a melancholy patient who thinks that he is dead and refuses to eat anything. There was a ruse. According to Forestus, the doctor asked an associate to pretend to be another corpse. He then put his stooge ‘in a chest like a dead man, by his bedside, and made him rear himself a little, and eat: the melancholy man asked the counterfeit whether dead men used to eat meat. He told them yay; and did eat likewise and was cured.’2 Again, this feels suspiciously rapid. The farce of a ‘dead body’ sitting up in a coffin to shock another person out of a delusion has a ghoulish entertainment value, but physicians were prone to talking up the success of ruses for their own reputational ends and it’s quite possible the trick was no more successful ultimately than the one pulled on the three ‘Christs’ or Pirandello’s Henry IV. These interventions were dubious long before they were considered unethical.
People with the delusion that they are dead won’t be easily revived, by any means, and walking corpses recur again and again. A persecuted melancholic in Tscherning’s poem ‘Melanchey redet selber’ of 1655 regularly fancies that he has died, or that he is hanging on the gallows.
A key shock factor with the delusion that you’re dead is the relative youth of the people experiencing it. They are typically somewhere in the middle of their lives, like ‘Madame X’. In 1788 the Swiss–French natural scientist Charles Bonnet encountered an elderly patient, and in this account the delusion is a very different proposition.3 This old woman apparently felt a draught and was paralysed down one side of her body. As per instructions, her daughters dressed her in a shroud and put her in a coffin. When she fell asleep they put her back in bed and gave her a powder containing opium, and this seemed to help, but the symptoms returned from time to time. This version of the delusion is more poignant, something like a memento mori.
Bonnet’s patient was an outlier. Most of the already-dead are not very advanced in years. In his lecture of June 1880 presenting ‘Madame X’ to the world, Cotard produces five further sensational cases of a delusion of negation. These cases came to him via Jean-Étienne Esquirol, who had reported these examples of what he called ‘demonomania’: one woman believing that the devil inhabited her body, torturing her, and she could never die. The second was convinced that the devil had taken her body away, she was only a ‘vision’ who had been alive for thousands of years, and that a malignant being in the shape of a snake lived in her womb. A third believed a bad spirit had stolen her body and she had no blood. The fourth said that she was made out of the devil’s skin and filled with snakes and toads; the fifth that she did not have a heart and as a consequence she, too, could not die. Cotard then cites two further cases in his lecture originally reported by François Leuret, a disciple of Esquirol. One man believed that he was damned and that he was a statue made out of imperishable flesh possessed by the devil. Like ‘Madame X’, he threatened to set fire to himself. The other, who was also damned and immortal, had a hole in his abdomen and was without a soul. He talks about the ‘strange logic’ and also the paradoxical nature of some of these cases of ‘hypochondriacal’ delusion, where patients say they are ‘neither alive nor dead, or that they are alive-dead’. These patients are described as being unhappy in their delusions of immortality. It’s a different kind of unhappiness from that connected with delusions of grandeur where people are frequently weighed down with heavy responsibility and sacrifice underneath their pompous confidence. Cotard mentions a man experiencing a hybrid of delusions. He ‘believed he would never die because his body was protected by certain privileges awarded to him by Napoleon himself’. Cotard notes that ‘hypochondriacal’ delusions, unlike anxious melancholia, seem to worsen over time. They tend not to end well. He is careful to separate the phenomenon from generic religious insanity.
Cotard continued feeling his way, trying to reveal his ‘Madame X’. He developed his thinking further, publishing a paper in Archives de Neurologie in 1882, and entitling it ‘Du délire de négations’. The word délire as Cotard meant it carries a far heavier freight of meaning than the English word ‘delusion’. Like the idea of melancholia, it is multi-dimensional and expansive. A ‘délire’ of ‘négation’ is complex, existing at the intersection of various complaints such as guilt and anxiety but they come together to represent something clear: complete and permanent self-annihilation. Cotard uses everything in his diagnostic repertoire to shed some light, to get through to her, maybe even to animate her.
As the character of ‘Madame X’ is styled by her doctor, Jules Cotard is himself reversioned through the mind of someone else. In his case it’s a master impressionist of bourgeois Parisian society, Marcel Proust. Proust gives Jules Cotard a cameo appearance in the second volume of À la recherche du temps perdu, Within a Budding Grove. The novel was published in 1918, thirty years after Cotard’s death. Cotard appears as the influential forward-thinker Professor ‘Cottard’, cunningly disguised with the addition of an extra ‘t’ in his name.
Jules Cotard was well known to the Proust family. Marcel Proust’s father, Dr Adrien Proust, was an eminent Parisian surgeon and a contemporary of Cotard at the École de Médecine. The junior Proust’s life overlapped with Jules Cotard’s for eighteen years, and so he was able to model the character of Cottard on a man who was not only an influential Parisian figure but someone he had observed at close quarters throughout his childhood.4
The real doctor disappears behind his literary persona but if Proust’s version is anything like faithful to the living, breathing Cotard, he was greatly admired in his professional life for his vision and diagnostic skill. We first meet the fictional version in À la recherche when ‘Cottard’ is introduced as a prospective dinner guest of the central Swann family. He is portrayed as a man with a brilliant clinical touch, diffident but solid as a rock in his diagnostic instincts. In the book, the most intelligent of the younger doctors apparently says ‘that if they themselves ever fell ill Cottard was the only one of the leading men to whom they would entrust their lives’.5 But Proust does not hold back in presenting the doctor’s flaws either:
Cottard’s hesitating manner, his excessive shyness and affability, had, in his young days, called down upon him endless taunts and sneers… Wherever he went…he would assume a repellent coldness, remain deliberately silent as long as possible, adopt a peremptory tone when he was obliged to speak, and never fail to say the most disagreeable things… Impassiveness was what he strove to attain, and even while visiting his hospital wards, when he allowed himself to utter one of those puns which left everyone, from the house physician to the most junior student, helpless with laughter, he would always make it without moving a muscle of his face, which was itself no longer recognisable now that he had shaved off his beard and moustache.6
There’s more than a touch of the ridiculous about Proust’s Cottard. He’s trying his best to seem aloof and authoritative but can’t pull it off. The students flock to him for advice but they find the man funnier than his jokes.
Jules Cotard was born at Issoudun in the Loire Valley in central France on 1 June 1840. His father was a bookseller and printer and, according to Antoine Ritti, the man who delivered his eulogy, a ‘serious and reflective character’ whose all-round, multi-discipline interests and education founded ‘a philosophy which embraced science, societies and their developments, with an ethic which had, at its base, human nature’.7 Cotard was an intern at Salpêtrière, where he first became interested in mental illness. Like his literary incarnation, he won prizes at medical school, and, just as Proust suggests, his colleagues came to him for consultations.
Like Capgras in the following century, Cotard is fresh from military service when he first meets the patient who will make his name. Their paths cross in 1874, only three years after the Franco-Prussian War, where he served as a physician in the infantry regiment in the French army. By 1871 he was back in Paris, treating the mentally ill, and, typically, also the poor, referred to him by the gendarmerie from all corners of the city. As with Joseph Capgras after the First World War, it is not difficult to imagine how a young doctor exposed to the traumas of physically and psychologically wounded soldiers might develop an enduring, even morbid, interest in the darker recesses of the human mind and the imaginative strategies that can develop in the dark.
The day Cotard sat down with ‘Madame X’ and heard about the lightning flash and cracking noise down her back, he had only just become the lead physician at Vanves. Vanves was a large private clinic with extensive gardens at a time when many European mental institutions were thinking about how to design the environment, inside and out, to be therapeutic. The German psychiatrist Maximilian Jacobi was working on this very question and visited Vanves as part of the whistle-stop tour for his report of 1841. He described how ‘the views…from the windows, embrace flowerbeds and shrubberies, beautiful landscapes, or the grand park… Whilst the range of view from the windows of the restless and maniacal patients is narrow and uniform, that from the windows of the melancholy patients is wide and variegated, surprising and delighting the eyes by the multitude of beautiful objects presented to it.’8 The view is designed to cater specifically for the ‘melancholy’ patients who are set apart from, and above, the others patients. A Tudor melancholic like Henry Percy wouldn’t be out of place in this scene, posing in the natural landscape with a high-minded sensitivity to his surroundings.
Cotard is interested in his new variety of melancholy. While at Vanves he writes four papers on the subject, developing his thoughts further each time, and showing a deep and enduring curiosity.
Over the course of these papers, Cotard references other cases of negation he has come across in his clinical practice at Vanves in the 1860s, 1870s and 1880s. He identifies recurring patterns: ‘If one asks them what their name is, they do not have one… They do not have an age. Where were they born? They were not born. Who were their father and mother? They have no father, mother and no children.’ One man refuses to wear clothes ‘because his whole body is nothing other than a large nut…he refuses to eat for he has no mouth; he refuses to walk for he has no legs.’9 Five out of eight cases refused to eat, and many more cases feature bowels and digestive systems not working. ‘Madame X’, of course, reported having ‘neither brains, nor nerves, nor chest, nor intestines’.
There were other cases that Cotard didn’t know about. Dr Clouston’s lecture at the Royal Edinburgh Asylum listed a variety of delusions reported by the women at the hospital. As well as describing the case of a woman who thought her legs were made of glass, he gave us other beliefs: ‘being followed by the police’, ‘the soul being lost’, ‘that the head is severed from the body’, ‘having neither stomach nor brains’, ‘her children being killed’ and ‘being dead’.
‘Madame X’ was not alone in her delusion, but her experience of it was lonely. At Vanves although her view of the grounds from her room was designed to lift her melancholic spirits and improve her wellbeing, nothing slowed the inexorable deterioration of her condition. Her negation delusion had a powerful religious dimension and related sense of doom which did not fade.
Cotard was still asking questions about the nature of her delusion. What did it come from? Why was it so unstoppable? We might ask, too, why he was interested in her. They were from the same generation and that gave them certain defining events in common. In particular, everyone had just lived through the protracted end of the Franco-Prussian War. Cotard, as we have seen, had served as a regimental physician in the infantry all the way through. ‘Madame X’ was admitted to Vanves just three years after the Siege of Paris which forced the end of the conflict. ‘Madame X’ would have been in her late thirties, unlike ‘Madame M’ who was a baby during the terrible years of the blockade. The years of siege correspond with the onset of ‘Madame X’s delusion.
Andrew Hussey, historian of Paris’s darkest chapters, writes of the truly gruesome reality of the food shortages for the people of Paris, resulting from Bismarck’s attempt to force surrender: ‘As the siege hardened,’ Hussey writes, ‘the most desperate among them took to digging up corpses in various cemeteries around the city, mincing the bones to make a thin sort of gruel, which offered little nutritional value but at least kept them warm.’ This astonishingly gruesome scene turned out to be a prelude to the glamorous belle époque, just around the corner but unimaginable at this point. By mid-October fuel was low, and the trees on the Champs-Élysées and the other great boulevards were chopped down for firewood. All but the wealthiest went hungry. Hussey brings us the notes of the theatre censor Victor Hallays-Dabot. On 10 November, he noted that ‘rats were being sold in Les Halles at 25 centimes each. An American, Wickham Hoffman, stationed at the American Legation, also recorded that dogs sold from 80 cents up, according to size and fat.’ Brewery rats were ‘a titbit’. On 5 January 1871, Bismarck began a relentless bombardment of Paris in which at least four hundred people were killed ‘by the same model of Prussian gun that had been proudly displayed in the heart of the city at the exhibition of 1867’.10 We don’t know how close ‘Madame X’ got to the reality of starvation but even the luckier ones were plagued by survivor’s guilt. She struggled for decades with the question of whether or not she was ‘worthy’ of food, or of anything for that matter. Everyone in the city was caught up in the trauma and humiliation. There was good reason for an unspoken mutual understanding between ‘Madame X’ and Jules Cotard.
There’s another, more opaque dimension to the delusion: the question of the religious crisis that ‘Madame X’ described in detail to Cotard, which apparently set in several decades before the Siege. She specifically mentions ‘having done wrong during her first communion’, and the guilt she felt as a result. She directs Cotard to this particular event, singling it out for attention, suggesting there’s an explanation to be found there. It’s an enigmatic reference. What could she have done wrong at a first communion?
She makes her strong religious faith clear. She was born within a year of the July Revolution of 1830 which replaced King Charles X with his cousin Louis Philippe, a pale imitation of Napoleon by all accounts and not inspiring source material for delusions of grandeur. But she grew up in a time when the church was tolerated again, after its suppression during the Revolution, and charitable Catholic institutions and congregations were flourishing. The public relations around being a Catholic still had to be well managed, however. A person’s first communion was a highly significant public occasion for a family, and especially meaningful at this point in time. In the early 1840s this would have taken place at twelve years old.
Manuals produced by the church taught children the protocol of their first communion and called it the most solemn and important event of a person’s life. The severest spiritual penalties for any transgression were made clear in black and white. Extensive preparation was called for. Special clothes were bought or hired for the ceremony and girls would be expected to wear clean white dresses to reflect the purity of their soul. Confession was a prerequisite for receiving the Eucharist and a child would have been visiting the confessional for about five years before first communion, since the age of seven or so. It was sacrilege to receive the sacrament in a state of mortal sin, as was failing to observe a fast from both solids and liquids from midnight on the day of the reception.
On the big day, the communicant kneels at the altar, the girls covering their hands in a linen cloth to avoid touching the host. An altar boy holds a tray below in case any crumbs of the host fall from the priest’s hands. The communicant is asked to reflect on what they, a miserable, poor sinner, are about to receive. This is the body of Christ. The communicant offers pleas, prayers and petitions for help to be worthy of the privilege. The extended family and wider community watch. A feast has been prepared at home where expensive presents await: a cross in ivory or gold, or rosary beads.
There are, then, many points in the proceedings when a girl could make a slip. So what did ‘Madame X’ do wrong? Perhaps she didn’t fast properly. Or stumbled as she went to kneel at the altar. Perhaps a crumb of the host fell. Or her clothes were not perfect. Perhaps she hadn’t confessed, or not to all her sins anyway. Whatever happened it was in front of the worldly authorities in her life, her parents and priest, as well as the divine.
Over the course of a confession to her physician decades later, ‘Madame X’ makes clear that, in her mind at least, this error turned her finest hour into a terrible humiliation and public shaming.
Whatever judgement she faced at home was complicated by the renewed scrutiny of the government of her family’s Catholic beliefs. By the time her illness set in, the religious climate for Catholics was much more unsettled. The Third Republic introduced many anti-Catholic laws and clergy of the Roman church were seen as being associated with the old regime. Numerous laws were passed to weaken the church’s hold on what was taught in schools. Republicans claimed that one of reasons the Germans had won the Franco-Prussian War was because of their superior education system. In 1879, priests were excluded from the boards of hospitals and charities. The anti-Catholic Jules Ferry Laws of 1882 were coming, and would mean that religious instruction was expressly forbidden.
Records don’t show if ‘Madame X’ married or had children of her own. Jules Cotard did both and was by all accounts a devoted father.
Someone in ‘Madame X’s birth family had access to enough money to be able to send her to a private institution like the one at Vanves with ambitions to be a therapeutic environment. Putting relatives into private institutions is a popular nineteenth-century literary trope, and the problem of what to do with an individual who lived in their own private reality was widespread but also shrouded in secrecy and shame. Delusions, like other forms of ‘madness’, were still touched with ideas of devilry, or moral frailty.
We don’t know what happened to ‘Madame X’ in the years before Vanves; the biography is a blank. Perhaps the best thing once again is to listen to the delusion itself. In the world she has created she is dead. Like Francis Spira, she has withdrawn from life. She is immune from prosecution for her actions or her character.
A person absenting themselves is a common feature of delusions. It’s there by another name in the torpor and inertia of ‘Madame M’ and our glass king, as well as in Andy Lameijn’s patient in Leiden who could go from being ‘there’ to being ‘not there’ at the flick of a switch. The records in Bedlam give us the account of Ellen Hamilton in 1892. She experienced paranoid delusions and claimed the people who were persecuting her down the telephone line ‘had murdered her on six occasions’. She ‘has no heart, no lungs, no body. Her brain had been cut out and she’d seen it lying about on the floor of the hospital…treatment with prolonged baths…still complaining that she was dead.’
Samuel Beckett wrote to the poet and critic Thomas MacGreevy about a visit to Bedlam in 1935, forty years after Ellen Hamilton’s time there. He describes how he ‘went round the wards for the first time, with scarcely any sense of horror, though I saw everything, from mild depression to profound dementia’. He seems to have kept himself at a distance from what he witnessed on that visit, but his later work suggests it influenced him profoundly.11 Several of Beckett’s characters talk after death, and with others the ‘I’ of the speaker disintegrates, resulting in a powerful sense of alienation. Beckett’s 1946 short story ‘The Calmative’ opens with the narrator declaring: ‘I don’t know when I died.’ The delusion of death makes itself useful in the twentieth century after the First World War. The person who thinks they are dead is the perfect nihilistic trope, just as the man who has lost his head was in France after the Revolution.
In a psychiatric context ‘Cotard’s syndrome’ came to be read as an extension of severe depression; a person’s explanation to themselves and other of their experiences of disassociation and alienation. In fiction walking corpses become vampire and zombie stories. There’s a spin on the conceit. The alienation is not from the point of view of the person who believes they are dead, but from the mind of those who fear it as an external threat. ‘Varney the Vampire’ was the first popular image of the living dead, the star of a gothic horror serial within the ‘Penny Dreadful’ magazines of the 1840s, and he was the warm-up act for Bram Stoker’s iconic creation Dracula in the novel of 1897. In the 1968 film Night of the Living Dead, director George Romero uses a cast of zombies to critique American society and the blind conformity of the population. Americans were in the middle of a war they couldn’t win (Vietnam) and audiences packed into movie theatres to watch the ‘Living Dead’ destroy civilisation as we know it. The archetypal zombie originated in Haiti where a ‘zombia’ was a figure stuck between life and death. In this original version, they are not simply the living dead, they are substitutes for loved ones. You recognise them, but they are not the real person. They provoke the same sense of familiarity and strangeness as ‘Madame M’s doubles. There’s a similar overlap in delusion stories. The boundaries between delusion types are permeable and different image systems often combine to express hybrid hopes and fears.
The living dead found their most shocking expression on film. Psychiatry, too, was exploring ideas of personal alienation and in 1960 R. D. Laing produced his landmark The Divided Self. It was a groundbreaking analysis of alienation as a psychological phenomenon. His central proposition was that mental disturbance came from the tension between the two personas inside us: our private identity and the self we present to the world. We derive our identity from others, and they from us, and if this transaction is insecure, crisis results. Laing was exploring how to treat his catatonic patients. They had completely withdrawn from the world. Some behaved as though they were already dead.
Laing attributes the catatonia in his patients to claustrophobic families and their demands. Here we’re reminded of Andy Lameijn’s reading of his patient who had been in an accident before the onset of his glass delusion. The parents, Lameijn surmised, had been overbearing as a result of the accident and this patient’s particular spin on the delusion meant he could disappear at will. In his 1964 book Sanity, Madness and the Family, he talks about withdrawal, ‘a strategy which a person invented in order to live in an unliveable situation’. In The Politics of Experience and the Bird of Paradise from 1967 he said that breaking your connection to the world was not necessarily ‘breakdown’ but could instead be a ‘break-through’. Being already dead was a response to interpersonal, social and existential factors, not just biological or neurological. It was a strategy. It made a lot of sense psychologically, and if a person was listened to, natural healing was possible without drugs or restraint.
Laing took Cotard’s idea of a delusion of negation into the 1960s. He shares an account of his encounter with a young patient who, like everyone else at the time, was living through the Cold War. ‘A little girl of seventeen in a mental hospital told me she was terrified because the Atom Bomb was inside her. That is a delusion. The statesmen of the world who boast and threaten that they have Doomsday weapons are far more dangerous, and far more estranged from “reality” than many of the people on whom the label psychotic is fixed.’ The little girl has turned her body into a warning about the threat of nuclear annihilation. He asks that old question: who should we consider delusional and who rational?
‘Cotard’s syndrome’ is rare, and, although persistent, it’s not yet fully understood. There are neurological explanations in play now along with the psychological theories, traced once again to right temporal lesions in the brain. The syndrome is associated with a disconnection between the sensory areas of the brain and the limbic system, which is responsible for emotions and memory. This breaks a person’s emotional relationship with the outside world and leads to feelings of unreality and delusions of death and negation. There’s a link to migraines, too, as well as the use of LSD.
Neurologists continue to find out more about the organic causes of delusions, through ever more sophisticated diagnostic technologies like the MRI scanner. In 2007 a variety of receptor encephalitis caused by an ovarian tumour and linked to delusions was identified by Josep Dalmau at the University of Pennsylvania. The growth instigates an autoimmune attack, but there are particular brain cells that resemble the embryonic cells in the ovary and they are mistakenly treated as though they present a similar threat and attacked also. The resulting encephalitis inflames the right hemisphere and delusions result. An American journalist, Susannah Cahalan, wrote about her experience of these delusions caused by an ovarian tumour in 2009 when she was twenty-four. In Brain on Fire: My Month of Madness, she details her paranoia, believing that her partner was unfaithful, as well as numbness down the left side of her body echoing the experience Charles Bonnet’s elderly Swiss woman who asked to be put in a coffin. She also had periods of catatonia. Practical tests showed that her spatial awareness was disordered and that the cause of the delusion was neurological not psychological. This type of delusion caused by an ovarian tumour is associated with grandiosity, and it can lead to violent hallucinations. Characteristic symptoms with this particular encephalitis include grunting and growling with convulsions and may even help to explain historic cases of ‘demonic possession’.
With ‘Madame X’, as with our other subjects, there’s the possibility of undiagnosed organic brain disease. Despite the continuing advances and shiny new technology, though, the brain and the mind remain profoundly mysterious and delusions elude a simple explanation of cause and effect. Psychological elements won’t be easily disentangled from biological, and each delusion is the product of multiple, overlapping influences and inciting factors which remain opaque.
In 1985, the neurologist Oliver Sacks published his bestseller The Man Who Mistook His Wife for a Hat, a series of essays outlining the case histories of some of his patients. The title of the book refers to one patient in particular, a man who suffered from ‘visual agnosia’, another disorder of recognition. Sacks makes the case that classical neurology has traditionally neglected disorders of the right hemisphere in favour of the more easily demonstrable malfunctions of the left. The right brain ‘controls the crucial powers of recognising reality which every living creature must have in order to survive’, but they are strange and mysterious and ‘somehow alien to the whole temper of neurology’.12
Despite the close-up view offered by MRI scanners, we are still in the foothills of understanding the mind. The Russian neurologist A. R. Luria, working in the earlier twentieth century, argued that an alternative neuroscience was needed: a ‘personalistic’ or ‘romantic’ science. This approach would be aligned closely with literary criticism and celebrate the literary qualities of case studies and the subjective and imaginative storytelling contained within them. In other words, we might get further in our understanding if we read an account like ‘Madame X’s as we read a fable. Sacks characterises his own subjects in The Man Who Mistook His Wife for a Hat as archetypes – heroes, victims, warriors. They ‘hark back to an ancient tradition: to the nineteenth-century tradition of which Luria speaks; to the tradition of the first medical historian, Hippocrates; and to that prehistorical and universal tradition by which patients have always told their stories to doctors’. Sacks suggests we listen to the stories themselves. He condemns modern methods which ‘could as well apply to a rat as a human being’. Today science is wary of the anecdotal and prefers to look instead to large quantitative analysis and control trials for its data. His plea is to ‘restore the human subject at the centre – the suffering, afflicted, fighting, human subject’; to look for the person and the particularities of their real life between the lines of the story they tell.
Delusions share a great deal with ghost stories, too. ‘Madame X’ buttonholes her doctor with a story about a lightning strike down her back, and her utter conviction about the revelation she is dead. The story leaves us with a sense of gothic menace, pre-empting Freud’s 1919 essay ‘The Uncanny’, or ‘Unheimliche’. For Freud, delusions, like dreams, are stories from the unconscious. By the time ‘Madame X’ was at Vanves and sharing her belief about being dead with her doctor, spiritualism had become popular in Europe. Central to the religion was the belief the disembodied spirit could be contacted in the hereafter and seances were a means by which to bring the messages through. ‘Madame X’s worldview is Catholic, but her version of living death doesn’t fit neatly into Catholic doctrine. She is even the conduit for an urgent message from the ether, in her case experienced as a jolt of electricity down her back almost as if taking part in a seance herself. She is passive, but she is also problematic, awkward and demanding further investigation.
Cotard saw ‘Madame X’s crisis as first and foremost a psychological one. We can’t know what neurological element may have been in the mix, if any, but there were certainly difficult experiences in her past exerting an influence, though the stories come to us incomplete. She brings up a specific event in childhood but then keeps it out of view. She was an adult during the years of war with the Prussians.
Cotard is working before Freud’s ideas arrive on the scene, but psychoanalysis would soon view trauma as the generator of madness, and uncovering the trauma, bringing murdered memories back into consciousness, as the road to cure. With her delusion she disconnects from this trauma. She removes these connections out one by one, disassembling her body so she doesn’t have a stomach, or guts, so there’s no need for any food, and she’s got no soul either. She says she is damned but then that God and the devil don’t exist either. She contradicts herself. She’s made herself disappear, but then tells her doctor that she wants to burn alive, like a heretic. She is not as blank as she first appears, then, there’s a faint request for redemption. But she won’t wait. She passes judgement on herself.
Jules Cotard tried to cure her, but he ran out of time, too. He’d been at Vanves for fifteen years when one of the infectious diseases creeping through the population came for him and he died aged forty-nine on 19 August 1889 from diphtheria. He’d contracted the disease while nursing his beloved daughter at Vanves. As she endured the illness’s characteristic fever, he had refused to leave her bedside for fifteen days.
Like Francis Spira three hundred years before her, ‘Madame X’ is reported to have starved to death.13